Managing patient satisfaction with full arch fixed restoration?

This patient had recently been restored with an implant supported full arch fixed restoration. Due to the restorative space, the prosthesis was designed with prosthetic gingiva in order to keep the tooth proportions appropriate. The patient was unsatisfied due to the visibility of the junction between her natural and prosthetic gingiva (Picture A). One way to avoid this is to pre-operatively assess the patient’s lip line when smiling and laughing. If the proposed junction is going to be visible, then it is likely that surgical planning must include enough alveolar ridge reduction (Picture B) to accommodate the patient’s smile. How would you have approached this situation? What techniques would you use to achieve a better esthetic result in a full arch fixed restoration?

Picture A

Picture B

IMHO this patient should have a snap on denture with a flange. This is a perfect example of jumping to perform a trendy and profitable procedure. I would not be surprised if this patient was even made aware of the potential esthetic concerns with a hybrid and was instead just ran through the protocol… Unfortunately this is not uncommon and I long for the day that the All on X trend passes.

Since the question was how to achieve a better result with a “full arch fixed restoration”, which I would not recommend for this patient, the damage is done now a lip repositioning procedure would be indicated. No amount of osseous resection is going to accommodate for this hyperactive lip so now is time to camouflage the mistake.

I am curious how doing a snap on with a flange would have made a difference since the patient’s lip line is so high. Wouldn’t you still be seeing flange across the board?

Flange covers the transition line. A complete maxillary denture with a flange will “always” prevent this. When attending a course describing the protocol for Full Arch treatment protocol, if it is a reputable organization sponsoring the course, they will always describe this. Not only does a flange eliminate the transition line it also fills the vestibule and prevents facial collapse and thus the appearance if aging.

Early on when I first started doing these cases I was extremely fortunate to have good mentors who were willing shared their own mistakes with me. The one thing that struck me was the tendency for this very thing to happen when dealing with younger people and/or those with a high smile. As a result I have always cautioned my patients about this possibility and when in doubt I will encourage them to consider a removable with a flange for the upper. I have actually upset some referring docs by mentioning this because they have zeroed in on the “cool factor” of performing these cases and been disappointed to discover their patient decide on a removable for the maxilla. I have no doubt that this particular case was well performed though I believe the team of docs or doc either overlooked this real possibility or they simply treated the patient as another full arch feather in their hat. It has always been my opinion that this treatment protocol is ideal for the mandible but merely an option for maxillary restoration. I have actually had people tell me that they don’t care and they will train themselves to smile and laugh differently because having a fixed restoration is that important to them. For the most part my patients are advised to seriously consider removable with a flange for the restoration of the upper arch…

Ok that does make sense. In the old days we would often over build the flange to give patients more lip support to rid them of that “caved in appearance”. Although I do agree that some people simply don’t want to wear something that comes in and out of their mouth from a psychological perspective, it can be difficult to convince them otherwise. Had there been more bone reduction do you believe this case could have been successful?

At what point do we stop removing vital bone and accept reality??? I would seriously consider a lip repositioning surgery in this case or just tell them the truth which is that the trendy stuff they see advertised on billboards is not the best option for them

Yes, a BoTox lip flip will hide more of the transition line or a filler.
Go to a nurse or a plastic surgeon as they have the most experience.